Amid epi­demic in Su­dan, of­fi­cials won’t say ‘cholera’

“As of July 7, health ac­tors had recorded more than 23,200 cases of acute wa­tery di­ar­rhea (AWD) since Au­gust 2016, ac­cord­ing to the U.N. World Health Or­ga­ni­za­tion (WHO) and the Gov­ern­ment of Su­dan (GoS) Min­istry of Health (MoH).”

“The U.S. Em­bassy in Khar­toum in­forms U.S. cit­i­zens that there are con­firmed re­ports of cholera cases in some ar­eas of Su­dan, in­clud­ing the greater Khar­toum metropoli­tan area, that have re­sulted in fa­tal­i­ties.”

— U.S. Em­bassy in Khar­toum, emer­gency mes­sage, June 1

The State Depart­ment and USAID are re­lated agen­cies, both re­port­ing to the sec­re­tary of state, but there is an odd dis­con­nect in how they have de­scribed a loom­ing pub­lic-health emer­gency in the African coun­try of Su­dan. The em­bassy de­clared that there were “con­firmed re­ports” of fa­tal cholera cases, whereas USAID, cit­ing the World Health Or­ga­ni­za­tion and the Su­danese gov­ern­ment, said there were cases of “acute wa­tery di­ar­rhea,” known in med­i­cal cir­cles as AWD.

What’s go­ing on here? The Facts Ac­cord­ing to the WHO, there are three types of di­ar­rhea: acute wa­tery di­ar­rhea, which lasts sev­eral hours or days; acute bloody di­ar­rhea, also called dysen­tery; and per­sis­tent di­ar­rhea, which lasts 14 days or longer. AWD can man­i­fest in cholera, which is an acute di­ar­rhea in­fec­tion caused by in­gest­ing food or wa­ter con­tam­i­nated with the Vib­rio cholerae bac­terium.

If left un­treated, cholera ill­ness can kill within hours. AWD is a symp­tom of cholera, but cholera ill­ness re­quires more ur­gent care and im­me­di­ate re­hy­dra­tion.

The first in­di­ca­tion of a prob­lem in Su­dan was in Au­gust 2016, when 100 deaths, mainly chil­dren, were re­ported in Su­dan’s Blue Nile state.

Su­dan has known lit­tle but civil con­flict since its in­de­pen­dence more than a half-cen­tury ago, es­pe­cially be­tween the largely Arab, Is­lamic north­ern part of the coun­try and the largely an­i­mist and Chris­tian African south, which formed the in­de­pen­dent coun­try of South Su­dan in 2011. There are also con­flicts in other parts of the coun­try, prin­ci­pally Dar­fur in the West and the Nuba Moun­tains and Blue Nile, which bor­der South Su­dan.

South Su­dan, the world’s youngest coun­try, de­scended into civil war shortly af­ter in­de­pen­dence, and a cholera out­break was de­clared there in May 2014. The first case was ret­ro­spec­tively iden­ti­fied as an on­set of ill­ness on April 23, and then four cases were lab­o­ra­to­rycon­firmed in Kenya; by May 25, of­fi­cials had re­ported 586 cases, in­clud­ing 22 deaths.

The WHO has as­sid­u­ously tracked the spread in the coun­try and ad­min­is­tered more than 1.5 mil­lion cholera vac­ci­na­tions in an ef­fort to stem the spread. Re­cent re­ports say an­other 2,500 cases in South Su­dan have been reg­is­tered since April, for a to­tal of 8,000, in­clud­ing 250 deaths.

The cholera out­break in South Su­dan is prob­a­bly linked to the grow­ing health emer­gency in Su­dan.

ACAPS, a non­profit, non­govern­men­tal project that as­sesses hu­man­i­tar­ian needs, on June 16 is­sued a re­port stat­ing that a “cholera out­break” that started in Blue Nile “be­gan to spread rapidly as of April this year. Con­ser­va­tive es­ti­mates sug­gest a min­i­mum of be­tween 15,000-23,000 peo­ple in­fected, with 280-820 deaths.” But the group said that with­out im­me­di­ate in­ter­ven­tion, in­fec­tion is likely to spread far­ther now that it has reached the densely pop­u­lated cap­i­tal of Khar­toum. More than 5 mil­lion peo­ple live in the city’s metropoli­tan area.

ACAPS said a fac­tor in the rapid spread might be the large refugee pop­u­la­tion from South Su­dan that fled the fight­ing and is crowded in refugee camps in the White Nile state. “ACAPS is cu­rat­ing and tri­an­gu­lat­ing a lot of dif­fer­ent sources to pro­duce its own in­de­pen­dent anal­y­sis,” said spokes­woman Caro­line Draveny. “In the case of Su­dan, all data we an­a­lyzed led us to call it cholera.”

In its re­ports in South Su­dan, the WHO ac­knowl­edged that “all the states bor­der­ing South Su­dan are af­fected” by a grow­ing num­ber of cases of acute wa­tery di­ar­rhea.

But here’s the prob­lem: The gov­ern­ment in Su­dan re­fuses to acknowledge even one.

In fact, Khar­toum has ac­tively sought to pre­vent hos­pi­tals, doc­tors and jour­nal­ists from re­port­ing a cholera out­break. As far back as Jan­uary, doc­tors re­ported that lab­o­ra­tory tests on acute di­ar­rhea sam­ples proved a di­ag­no­sis of cholera.

Al-Fateh Omar al-Sayed, a leader of the Su­danese Doc­tors Union and the Na­tional Epi­demi­o­log­i­cal Cor­po­ra­tion, in June told Ra­dio Da­banga, an in­de­pen­dent news source, that the cholera epi­demic has turned from a se­vere tem­po­rary sit­u­a­tion to a con­stant epi­demic. But the Su­danese gov­ern­ment has taken steps to play down the threat:

In April, news­pa­per re­porter Am­mar al-Daw was de­tained for re­port­ing on the out­break and ac­cused of defama­tion by the health min­is­ter of his home state, Gedaref, of vi­o­lat­ing the In­for­ma­tion Crimes Act.

In June, the Su­danese health min­istry fired a hos­pi­tal di­rec­tor who dared to pub­licly say the in­sti­tu­tion was treat­ing cholera cases.

In July, se­cu­rity of­fi­cers ques­tioned a group of vol­un­teers who had set up an aware­ness cam­paign on how to pre­vent the spread of cholera in the area. “The vol­un­teers were told to stop men­tion­ing cholera,” Ra­dio Da­banga re­ported.

Gre­gory Hartl, a WHO spokesman, said: “WHO has not re­ceived any lab re­sults to date that con­firm cholera in Su­dan. How­ever, the Gov­ern­ment of Su­dan has con­firmed an out­break of AWD. Pre­vent­ing the spread of the AWD out­break and sav­ing lives are two of the high­est pri­or­i­ties for WHO and Su­dan’s Fed­eral Min­istry of Health.”

He added that “whether an out­break is called ‘cholera’ or ‘acute wa­tery di­ar­rhea’ does not al­ter WHO re­sponse.” He did not re­spond to a query about whether a cholera dec­la­ra­tion would al­low the use of the cholera vac­cine to pre­vent fur­ther spread of the dis­ease.

In an open let­ter to the WHO, a group of U.S. physi­cians have de­cried “WHO’s fail­ure to con­firm the find­ings of Su­danese labs tests in Geneva, us­ing stool sam­ples ap­pro­pri­ately trans­ferred from Su­dan.” Ad­dress­ing WHO Direc­torGen­eral Te­dros Ad­hanom Ghe­breye­sus, the let­ter said: “Your fail­ure to trans­port stool sam­ples from vic­tims in Su­dan to Geneva for of­fi­cial con­fir­ma­tion of cholera makes you fully com­plicit in the ter­ri­ble suf­fer­ing and dy­ing that con­tin­ues to spread, out of con­trol, with daily new re­ports con­firm­ing that this is in­deed a cholera epi­demic.”

When he was health min­is­ter of Ethiopia, Dr. Te­dros, as he is known, was ac­cused of cov­er­ing up cholera out­breaks by la­bel­ing cases as AWD to avoid harm­ing the coun­try’s tourism in­dus­try. Tests by the United Na­tions con­firmed cases were cholera and had led to 60,000 in­fec­tions and more than 600 deaths.

WHO’s Hartl in­sisted: “Send­ing stool sam­ples over­seas is not called for at this point.”

A USAID spokesman noted that “typ­i­cally, a cholera out­break is de­clared by the Min­istry of Health in the af­fected coun­try, in co­or­di­na­tion with the World Health Or­ga­ni­za­tion. In Su­dan, there is no of­fi­cial cholera dec­la­ra­tion.” He said USAID was responding to the AWD out­break and added: “The United States calls on the Gov­ern­ment of Su­dan to sup­port timely test­ing and iden­ti­fi­ca­tion of the causes of acute wa­tery di­ar­rhea, in or­der to en­able both gov­ern­ment and in­ter­na­tional donor ef­forts to ad­dress the im­me­di­ate out­break, and pro­vide longer-term so­lu­tions.”

Rep­re­sen­ta­tives of the Su­danese em­bassy in Washington and Su­danese mis­sion to the United Na­tions did not re­ply to queries about the gov­ern­ment’s han­dling of the health emer­gency. The Pinoc­chio Test We un­der­stand the diplo­matic niceties here. A coun­try’s health min­istry is sup­posed to de­clare a health emer­gency, and the WHO might be re­luc­tant to in­ter­vene for fear that the regime would eject needed med­i­cal pro­fes­sion­als. But it seems ab­surd for the State Depart­ment to warn Amer­i­cans of con­firmed re­ports of deaths from cholera while USAID sticks with the more po­lit­i­cally con­ve­nient des­ig­na­tion of acute wa­tery di­ar­rhea, even as the death toll rises.

Amaz­ingly, the death toll might be higher (800) in Su­dan than in South Su­dan (250), but that’s be­cause the WHO has been able to re­spond to the cri­sis in South Su­dan with a pro­gram of vac­ci­na­tions and ed­u­ca­tion about the deadly dis­ease. The Pinoc­chios here are mainly for the Su­danese gov­ern­ment, which re­fuses to ad­mit an ap­par­ent cholera out­break, but the WHO and USAID should not es­cape blame, ei­ther. Words make a dif­fer­ence. The ac­cu­sa­tions that WHO’s di­rec­tor-gen­eral tried to mask a cholera out­break in Ethiopia by la­bel­ing it as AWD when tests showed oth­er­wise make it even more im­per­a­tive that the in­ter­na­tional agency should ap­pear above pol­i­tics.

FABIO BUCCIARELLI/AGENCE FRANCE-PRESSE/GETTY IMAGES

A cholera pa­tient lies in bed at a hos­pi­tal in South Su­dan. Re­gional of­fi­cials have avoided dis­cussing the out­break in con­crete terms.